, , , , , , GYNAECOLOGY , , , , , ,

LITIGATION FOLLOWING URETERAL

INJURIES ASSOCIATED WITH
GYNAECOLOGICAL SURGERY

George A. Vilos, MD,l

Donald J. Dow, Esq, 2
Hugh H. Allen, MD,3

1,3Professors of Obstetrics and Gynaecology,

Department of Obstetrics and Gynaecology,
Division of Reproductive Endocrinology,
St. Joseph's Health Centre,
University of Western Ontario,
2Gowling, Strathy & Henderson,
Barristers and Solicitors,
Ottawa, Ontario

ABSTRACT
Ureteral injury is one of the complications inherent in any gynaecological pelvic surgery. From the. beginning of this century, the range of
ureteral injuries during starulard gynaecological surgery has been reported to be between 0.04 and 1.46 percent, with a mean of 0.21 per-
cent (234 injuries in 110,351 operations, 1902-1998). The. mean ureteral complication rate is essentiaUy the same for the three kinds of
hysterectomies performed by most gynaecologists (laparascopic-assisted vaginal hysterectomy [LAVH]--O.4 2%, total abdominal hysteroc-
tomy [TAH]--O .18%, vaginal hysterectomy [VH]--O. 25%). Ureteral injuries occur across the range of pathological conditions, operators
and operative techniques which suggest that there is a critical incidence of ureteral injury below which gynaecological surgery has not been
able to fall (in the range of 0.1 to 0.5 percent). This may be because the exact position of the ureter is not constant. The. course of the ureter
as it crosses beneath the uterine artery, as close as one to two em from the lateral aspect of the uterus, is such that the margin for error is very
small.
In this report, we summarize the arcumstances, allegations and conclusions of 13 Caruu1ia.n resolved cases of litigated ureteral injuries
sustained during gynaecological surgery. By reviewing these cases, surgeons may familiarize themselves with the most frequent allegations
brought by plaintiffs, and the questions and prindples that judges apply in reaching their conclusions. In all 13 cases, the allegation of informed
consent failed as a reasonable person would have agreed to surgery under the conditions, even if the risk of ureteral injury had been disclosed.
Furthermore, the risk of ureteral injury does not have to be disclosed because it is a known complication with a frequency of occurrence of
less than 0.5 percent and it is not considered a material risk. The. use of a pre-operative NP, ureteral stenting or intra-operative dyes is of
little value in preventing ureteral injuries. In nine of the 13 cases (70%) the judge ruled in favour of the deferulant.
The cardinal rules in the management of ureteral injuries during gynaecological surgery are prevention, identification of the injury intra-
operatively and a high index of suspicion postoperatively.

JOURNAL SOGe 31 JANUARY 1999

 , , ,
RESUME
Les lesions ureterales representent un type de complications inherent a la chirurgie gynecologique du pelvis. Depuis Ie debut du 20 e siecle, Ie
taux de lesions ureterales resultant d'une chirurgie gynecologique nonnale s' etend entre 0,04 et 1,46 pour cent, et la moyenne est de 0,21
pour cent (234 lesions sur 110 351 operations, de 1902 a 1998). Le taux moyen de complications ureterales est essentiellement Ie meme
pour les trois types d' hysterectomies pratiquees par la majarite des gynecologues : I' hysterectomie vaginale accompagnee d' une /aparoscopie
(HVLA), 0,42 pour cent; l'hysterectomie abdominale totale (HAT), 0,18 pour cent; l'hysterectomie vaginale (HV), 0,25 pour cent. Les
lesions ureterales se produisent independamment des conditions pathologiques, des intervenants et des techniques d'intervention. Cela indique
qu'il existe un seuil minimal de lesions ureterales sous lequella chirurgie gynecologique ne peut descendre (il se situe entre 0,1 a 0,5 %). La
cause peut provenir du fait que la position exacte de l'urerere n' est pas constante. La localisation de l'urerere lorsqu'il passe sous l' arrere
uterine a une proximite allant de un a deux centimetres de la face laterale de I' uterus est telle que la marge de manoeuvre est tres petite.
Ce rapport presente un resume des circonstances, des allegations et des conclusions de 13 cas de litige canadiens portant sur les lesions
ureterales subies durant une intervention chirurgicale gynecologique. Une connaissance de ces cas permettra aux chirurgiens d' etre conscients
des allegations les plus frequentes des demandeurs ainsi que des questions que posent les juges et des principes auxquels ils ont recours pour
justifier leurs decisions. Dans les 13 cas, I' allegation de consentement edaire n' a pas ete retenue puisque, dans les circonstances qui avaient
rendu l'intervention chirurgicale necessaire, wute personne raisonnable aurait consenti a l'intervention meme en pleine conscience du risque
de lesion. De plus, etant donne que Ie risque de lesion ureterale est I' une des complications possibles connues, que sa frequence est
inferieure a 0,5 pour cent et qu'il ne constitue pas un risque important, il n' est pas necessaire d' en informer la patiente. Les recours a-l'uro-
graphie intraveineuse preoperawire, au moulage ureteral ou aux colorants peroperawires s' averent de peu d' utilite pour la prevention des
lesions. Dans 9 des 13 cas (70 %), Ie juge a decUli en faveur du defendeur.
La regie fondamentale dans la gestion des lesions ureterales associees a une intervention chirurgicale gynecologique, c' est la prevention,
l'identification de la lesion durant l'operation et un degre eleve de suspicion apres l'operation.
J soc OBSTET GYNAECOL CAN 1999;21(1):31-45
KEY WORDS
Litigation, ureteral injuries, gynecological surgery .

Received on June 16th, 1998, Revised and accepted on August 17th, 1998.

INTRODUCTION pattern emerging from these cases might help surgeons

With the increased use oflaparoscopic surgery, there
appears to be a parallel increase in complications, includ-
ing ureteral injuries. Such injuries usually occur during
laparoscopic-assisted vaginal hysterectomy (LAYH)
and/or salpingo-oophorectomy. However, the true inci-
dence of laparoscopic ureteral injuries is unknown. From
the available but limited publications describing laparo-
scopic ureteral injuries, it appears that the incidence is
the same as that of ureteral injuries associated with
abdominal or vaginal gynaecological surgery (Tables 1
and 2).
In this report, we summarize the circumstances, alle-
gations and conclusions of 13 resolved Canadian cases
of litigated ureteral injuries sustained during gynaeco-
logical surgery. By reviewing these cases, surgeons may
familiarize themselves with the most frequent allegations
brought by plaintiffs, and the questions and principles
that judges apply in reaching their conclusions. The
to avoid causing such injuries and to deal with potential
or ongoing litigation.
In medical malpractice cases of ureteral injuries,
statements of claim will generally allege lack of informed
consent and a breach of the applicable standards of care.
INFORMED CONSENT
There are three elements to the doctrine of informed
consent: l
i) The Duty of Disclosure-did the defendant physi-
cian discharge the duty to outline the basic nature
and character of the operation to be performed? In
some instances, this will also require a discussion of
alternative therapies or treatments.
ii) Materiality of the Risk-was the complication
alleged to have occurred a risk that would have been
considered "material" and one that should have been
disclosed? A material risk is defined as a risk of high
frequency (greater than 1%) or a risk that, although

JOURNAL SOGC 32 JANUARY 1999

 The primary cause of acne is over-production of sebum, which is linked to
androgens. Diane-35 is the first antiandrogen/estrogen pill indicated for the
treatment of women with severe acne (unresponsive to oral antibiotics and other
available treatment) with associated symptoms of androgenization including seborrhea and mild hirsutism. When taken as recommended,
Diane-35 will also provide reliable contraception with a side effect profile comparable to that of oral contraceptives.*

Treating severe acne while providing reliable contraception t

Diane"·35 (cyproterone acetate and ethinyl estradiol) is indicated for the treatment of women with severe acne, unresponsive to oral antibiotic and other available treatments,
with associated symptoms of androgenization, including seborrhea and mild hirsutism. t Diane-35 should not be prescribed sole~ for its contraceptive properties_ However,
BERLEX CANADA INC. [ffi[] (.;:.:;,) when taken as recommended, Diane-35 will provide reliable contraception, -Please refer to full prescribing information for precautions and patient seledion criteria
 , , ,

remote, because of possible gravity of the conse-
quences (i.e. death or major impairment), should
have been disclosed.
iii) Causation-if a physician fails to obtain informed
consent, liability attaches only where it can be
established that a reasonable person in the patient's
position, on a balance of probabilities, would have
decided against a particular surgical procedure had
he or she been properly informed.
In the context of a civil action, the Court will look
beyond the actual consent form and will focus on the
process by which consent is obtained. Courts increas-
ingly look to objective evidence that the patient under-
stood the information provided. Factors that will be
considered include:
1) whether the patient asked any questions;
2) whether diagrams or visual aids were used to com-
municate what was involved;
3) whether the information was put in writing;
4) whether the time spent with the patient was realis-
tic in terms of the patient's ability to understand the
complexity of the procedure.
In determining whether or not risks of a procedure were
discussed, the Court will scrutinize the available docu-
ments. It is very helpful to the doctor to make a notation
on the clinical record indicating that the nature and risks
of the procedure were discussed.
In cases involving ureteric injury, because the risk of
injury is relatively low, provided the indications for surgery
are appropriate, the causation aspect of consent defeats
most claims, as most patients in these circumstances would
In cases involving ureteric injury, the allegations of
negligence that may be raised include the indications
for surgery, performance of the surgery and alleged fail-
ure to diagnose and treat properly the complication that
resulted.
In determining negligence following ureteral injury,
judges rely on several factors including the testimonies of
the plaintiff, the defendant and the expert witnesses. The
basic questions considered by judges are the following:
1. Given the patient's history, signs and conditions at
the time, was the proposed surgery an acceptable
option to give to this patient?
2. Did the surgeon perform the surgery within the stan-
dard expected of a gynaecologist, trained and expe-
rienced in the practice of the procedure? The
resolution of this question relies on the defendants'
testimonies, their records, the opinions offered by the
experts and the interpretations of the overall evi-
dence by the judges.
3. Is damage to the ureter a known and accepted com-
plication of the surgical procedure? Ureteral injury
is a known complication in any gynaecological
surgery. Injury may be caused by one of five types of
trauma; crushing, ligation, transection, angulation
(kinking) or devascularization with secondary
obstruction or leakage of urine. Table 1 summarizes
the publications describing ureteral injuries during
TABLE 1
URETERAL INJURIES ASSOCIATED WITH GYNAECOLOGICAL

go ahead with the surgery, even if the frequency and sever- r-

Authors
._--
SURGERY (NOT LAPAROSCOPy)
Study I
Number of Ureteral Percent
ity of the potential complications were known. Period Surgeries Injuries
r-- - 4,086""
Sampson, 19022 - 32 0.78
STANDARD OF CARE Newell, 19393 - 3,144 13 0.40
Medical-standard negligence is an allegation that the Benson and Hinmann - 6,211 36 0.S8
19554
defendant doctor has failed in the duty towards the
patient by not exercising the degree of care, competence
Everett and Mattingly - 15,000 39 0.26
19565
or skill which could reasonably be expected of a normal, Daly and Higgins 1980-1985 1,093 16 1.46
prudent practitioner of the same experience and stand- 19886

ing and under the same or similar circumstances. If the Mann, 1991 7 1980-1989 4,195 16 0.38
Thompson, 19928 1959- 1977 9,171 39 0.43
plaintiff does establish a breach of standard, it must then
Goodno et a/. 1995 9 1983-1992 4,665 19 0.41
be demonstrated that the defendant's breach of duty is
Scott and Webster 1992-1994 3,147 2 0.06
causally connected to the plaintiff's injury. The plaintiff 1996 ' 0
must prove on a balance of probabilities that, but for the Harkki·Siren et a/. 1990-1994 59,639 22 0.04
tortious conduct of the defendant, the plaintiff would not 1998

have sustained the injury of which she is complaining. Total

"
1902- 1998 110,351 234 [ 0.21
'-

JOURNAL SOGC 34 JANUARY 1999

 , , ,
standard gynaecological surgery since the beginning
of this century. The range of ureteral injuries is 0.04
to 1.46 percent with a mean of 0.21 percent. l . ll
Ureteral injury has not been considered a material
risk, and judges accept it as a known complication.
Table 2 summarizes the publications dealing with
ureteral injuries during such specific hysterectomies
as laparoscopic-assisted vaginal hysterectomy
(LAVH), total abdominal hysterectomy (T AH),
subtotal abdominal hysterectomy (SAH) and vagi-
nal hysterectomy (VH) . The mean ureteral compli-
cation rate is essentially the same for all methods of
hysterectomy. It appears, regardless of the kind of
hysterectomy gynaecologists perform, that there is
an irreducible risk of ureteral injury in the range of
0.02 to 1.4 percent. . 9 14
4. Can such damage occur even where the requisite
care and standard precautions are taken by the physi-
cian to avoid damage to the ureter? There are four
methods proposed to prevent intra-operative ureteral
injury.B
a) Pre-operative intravenous pyelogram (IVP).
Pre-operative IVP to identify the position of the
ureter in patients with extensive pelvic disease,
especially tumours, h as been advocated in the
past. However, ureteral injuries during surgery in
patients who have had a pre-operative IVP do
occur with the same frequency. Simel et al. in
1988 performed a theoretical analysis of ureteral
injuries during hysterectomyY They estimated
that 833 pre-operative IVPs would have to be
done to prevent a single ureteral injury, and that
it would cost approximately $3.33 million to
prevent one death from this complication. Pre-
operative IVP has not been
shown to reduce ureteral
injuries associated with TABLE 2
pelvic surgery. URETERAL INJURIES ASSOCIATED WITH HYSTERECTOMY (LAVH, TAH , SAH, VH)
b) Pre-operative ureteral
r-
Author
stenting. This requires a Scott and Webster
1996 10
urologist to perform a pre-
hysterectomy procedure
Mlekle et a/. 1997 12 6/2,273 (0.3%)
Saidi et al. 199613 , 1/489 (0,2%)
and insert a ureteral catheter
Hulka eta/. 1997 14 :401/14,911 (0.3%)
cystoscopically, or would
Goodno et al. 19959
require all gynaecologists to Harkki-Siren et a/.
acquire the skills necessary 1998 11
for cystoscopic placement Total
JOURNAL SOGC
of the ureteral stents. A cost-benefit analysis of
such a procedure has not been determined. Fur-
thermore, except in such rare circumstances as
vaginal hysterectomy for procidentia and vault
repair, pre-operative placement of ureteral
catheters has not been demonstrated to be help-
ful in preventing injury. The placement of ureter-
al stents can occasionally be helpful by making
the ureter easily palpable and, thereby, identifi-
able during laparotomy or vaginal hysterectomy.
However, it has been unsuccessful in eliminating
ureteral injuries and it may be falsely reassuring. 16
Stents decrease the natural ability of the ureters
to fall away from the operative field and may
make the ureters more vulnerable to injury.tO
c) Intra-operative visualization. Direct visualiza-
tion of the ureters has been the most reliable and
valuable method used to prevent ureteral
injuries. 6,B,16 In the region where the ureter pass-
es underneath the uterine artery, direct visual-
ization is not possible as the ureter enters a
tunnel surrounded by the major blood vessels
and cardinal ligaments of the uterus. Attempts
to dissect the ureter at this point may result in
more serious complications including major
bleeding and ureteral injuries.
d) Ureteral dissection. Surgery residents are taught
routinely to expose the ureter at the pelvic brim
during a laparotomy. In almost all cases, it can
be easily traced from this point down to within
approximately one centimetre of where it passes
under the uterine artery. At times, the dissec-
tion itself may result in such major complica-
tions as bleeding from the major pelvic vessels
-
VH
LAVH TAH
- . SAH _
f- -
0/19 (0%) 1/340 (0 .29%) - -
0/434 (0%) - -
- - -
- - -
-
- 10/2,471 (040%) i S/1 ,054 (0.47%)
38/2,741 (14%) 18/43,149 (004%) 3/10,854 (0,03%) 1/S,636 (0.02%)
..
0.42% 0.18% 0.03% 0.25%
35 JANUARY 1999
 , , ,
or devascularization of the ureter which may lead
to ureteral necrosis and narrowing or obstruction
from fibrosis. The risk of devascularization
remains low if the ureter itself is not dissected off
the medial peritoneum.
The inevitable conclusion is that although there are
several steps that can be taken to decrease the risk of
ureteral injury, none is foolproof. The reports (Tables
1 and 2) highlight that ureteral injuries occur across
the range of pathological conditions, operators and
operative techniques,9 suggesting that there is a crit-
ical incidence of ureteral injury below which gynae-
cological surgery has not been able to fall (in the
range of 0.2 to 0.5%). This may be due to the fact
that the anatomy of the ureter as it crosses beneath
the uterine artery, due to biological variability, is as
close as one to two centimetres from the lateral aspect
of the uterus, and the margin of error is very small.
The exact position of the ureter is not constant.
5. Was the postoperative care of the patient in accor-
dance with the standard of care expected under the
circumstances? The resolution of this question again
depends on the evidence of the plaintiff, the defen-
dant, the experts, the clarity and extent of the hos-
pital record and the interpretation by the judge.
Having summarized the legal foundation of malprac-
tice suits, we will now discuss the 13 Canadian cases.
CASE REPORTS
CASE 1: LEFT OOPHORECTOMY, DAMAGED
LEFT URETER, DECEMBER 1984
FACTS
A 27 -year-old mother of two presented to the emer-
gency department with acute left lower quadrant pain.
Ultrasound demonstrated an eight-centimetre ovarian
cyst. She had previously had laparoscopic tubal occlu-
sion and abdominal hysterectomy with right salpingo-
oophorectomy for chronic pelvic inflammatory disease.
During laparotomy, a 10-cm cystic mass filling the
entire pelvis was noted. The surgeon used blunt dissec-
tion with his fingers to loosen the mass from its adher-
ent surroundings, and subsequently clamped, cut and
ligated the infundibulopelvic ligament. Postoperative-
ly, the surgeon left town but had arranged coverage. On
the third postoperative day, the patient developed
JOURNAL SOGe
abdominal pain and shortness of breath. An IVP
showed urine leakage into the abdomen. A urologist
found free urine in the abdomen and a one-cm necrotic
area of the left ureter six cm from the bladder. The
ureter was re-implanted and the patient made an
uneventful recovery.
ALLEGATIONS
Lack of informed consent and medical-standard neg-
ligence. The plaintiff argued that the ureter should have
been identified and dissected out.
JUDGEMENT
June 1995. The judge concluded that the risk of dam-
age to the ureter was not a material risk that needed to be
disclosed. Furthermore, the patient, a reasonable person,
would have agreed to go ahead with the surgery even if
she had been informed of the full risks of this surgery
because of her underlying condition. The judge accepted
the defendant expert's evidence that the prophylactic
procedures (the use of a catheter, the use of pre- operative
IVP and the use of intra-operative dye) suggested by the
plaintiff's experts posed certain risks in themselves and
that it was not negligent to have omitted their use. The
judge concluded that this was a misadventure and not
negligence. The action was dismissed.
CASE 2: RIGHT OOPHORECTOMY, SEVERED
RIGHT URETER, JUNE 1989
FACTS
Following a remote abdominal hysterectomy and left
salpingo-oophorectomy, the patient complained of
chronic unbearable pelvic pain. An IVP was normal.
Laparoscopy demonstrated multiple pelvic adhesions
with the right adnexa stuck to the pelvic side wall. The
gynaecologist recommended removal of the right adnexa
and the patient agreed. Informed consent was not an
issue. During laparotomy, the surgeon used blunt finger
dissection to peel the ovary away from the peritoneum
over the ureter. He then opened the peritoneum, put his
fingers through it and clamped, cut and ligated the
infundibulopelvic ligament. Unfortunately, the ureter
was included in this pedicle, and approximately one cm
of the ureter was removed with the specimen. The ureter
was subsequently repaired uneventfully.
36 JANUARY 1999
 After as little as 6 months of therapy, new Diane-35 can produce results like the actual case shown here'. Diane-35
is the first antiandrogeniestrogen pill indicated for the treatment of women with severe acne, (unresponsive to oral
antibiotics and other available treatment) with associated symptoms of androgenization including seborrhea and mild
hirsutism. When taken as recommended, Diane-35 will also provide reliable contraception with a side effect profile
comparable to that of oral contraceptives:

Treating severe acne while providing reliable contraception t

Diane"'-35 (cyproterone acetate and ethin~ estradiol) is indicated for the treatment of women with severe acne, unresponsive to oral antibiotic and other available treatments, with

BERLEX CANADA INC. lillIl (;;;;:';:cl associated symptoms of androgenization, including seborrhea and mild hirsutism. t Diane-35 should not be prescribed solely for its contraceptive properties. However, when taken
as recommended. Diane-35 will provide reliable contraception, *Please refer to full prescribing information for precautions and patient selection criteria. 'Data on file.

I ,,·il'
 , , ,
ALLEGATION
Medical-standard negligence.
JUDGEMENT
July 1995. The judge accepted the evidence of
one defence expert that it is not always necessary to
identify the ureter before cutting or removing tissue.
However, in this case "the ureter was there to be seen."
The fact that the defendant did not visualize what
structures he had grasped when it was known that the
ureter was in close proximity to the structures amounted
to negligence. Judgement was granted in favour of the
plaintiff.
CASE 3: HYSTERECTOMY, LIGATED RIGHT
URETER-NEPHRECTOMY, MAY 1983
FACTS
A middle-aged patient who had previously been
treated for psychiatric problems and had had surgery for
ovarian cysts underwent an elective hysterectomy by the
local general surgeon for severe menstrual pain. Two
years later it was discovered that the right ureter was
blocked, the kidney was nonfunctional and a nephrec-
tomy was performed.
ALLEGATIONS
Lack of informed consent, insufficient indications for
hysterectomy, negligence in performing the hysterecto-
my and negligence in failing to diagnose postoperative
complications.
JUDGEMENT
February 1997. The judge held that the failure to
advise of the risk of ureteric injury did not nullify the
consent. The judge noted that there was expert evi-
dence supporting the decision to operate. The judge
further determined that ureteral injuries occur without
an inference of negligence being drawn. The standard
of care for a general surgeon under the circumstances
could not be compared to a gynaecological standard of
care. With respect to follow-up, nothing in the
patient's medical record would have reasonably given
rise to a blockage of the right ureter. The action was
dismissed.
JOURNAL SOGC
CASE 4: BILATERAL OOPHORECTOMY, RIGHT
URETERAL OBSTRUCTION-NEPHRECTOMY,
JULY 1985
FACTS
A 28-year-old patient with a long previous surgical
history including one delivery, cholecystectomy, appen-
dectomy, tubal ligation, right oophorocystectomy and
hysterectomy with left oophorocystectomy continued to
complain of chronic pelvic pain not responding to med-
ical therapy administered by her regular gynaecologist.
Accordingly, she underwent laparotomy and bilateral
salpingo-oophorectomy performed by her gynaecologist's
locum. The ovaries were stuck to the pelvic wall by dense
adhesions of endometriosis. The pedicle was triple-
clamped and tied with O-silk suture. The ureter had been
identified and was free of clamps and ligatures. Immedi-
ately following the surgery, before she was discharged, the
patient complained of nausea, vomiting, right flank pain,
dysuria and developed a low-grade fever. A urine test
ruled out the possibility of a bladder infection, but the
patient was discharged with oral antibiotics without fur-
ther investigation. The patient saw her regular gynaecol-
ogist six weeks after discharge and on four occasions
thereafter,. About five months after discharge, an intra-
venous pyelogram indicated that her right kidney was
nonfunctional as a result of ureteral obstruction. Nephrec-
tomy was performed after failed ureteral re-implantation.
ALLEGATIONS
Lack of informed consent, negligence during surgery
(locum doctor) and negligence in failing to detect the
injury sooner (both doctors).
JUDGEMENT
October 1995. The issue of informed consent was
abandoned during argument. The judge concluded that
the locum doctor was negligent in both the conduct of
surgery and failure to investigate the patient's com-
plaints prior to discharge. The judge was presented with
conflicting evidence as to whether or not the surgeon
ought to have dissected out the ureter. The judge con-
cluded that the surgeon was negligent in not having
addressed the need for dissection. The doctor failed to
consider the possibility of dissecting the ureter during
surgery. Complaints of low-grade fever, flank pain and
dysuria were all indicative of damage to the ureter. The
38 JANUARY 1999
 , , ,
judge concluded that had the locum doctor investigat-
ed these symptoms and discovered the damage within
two weeks of the operation, the ureter could have been
re-implanted without consequence. Negligence against
the regular gynaecologist was dismissed, finding that
there was no evidence that diagnosing the injury at six
weeks would have prevented the damage to the kidney.
CASE 5: BILATERAL OOPHORECTOMY, LEFT
URETERAL OBSTRUCTION, JUNE 1992
FACTS
A 36-year-old mother of three had laparoscopic
drainage of a right ovarian cyst followed at a later date by
a hysterectomy for cervical dysplasia. Subsequently, she
complained of chronic intermittent right lower quadrant
pain, and an ultrasound confirmed a three-cm right ovari-
an cyst. When conservative treatment failed to relieve the
pain, surgery was recommended. It was agreed that the doc-
tor would perform a laparoscopy but might convert to
laparotomy if laparoscopy were too difficult. The patient
agreed to the possible removal of her right ovary but was
concerned about the possibility of having to take hormone
replacement therapy as her mother had died of breast can-
cer at a young age. Laparoscopic exploration of the pelvis
showed extensive scarring around the left: ovary with a large
left: ovarian mass present and a moderate sized right ovari-
an cyst with much bowel scarring to it. The laparoscopy
was converted into a laparotomy, and the left: ovary was dis-
sected free from the pelvic side wall with sharp dissection.
The pedicle was cross-clamped, divided and suture-ligated.
The ureter was identified well below the area of dissection
and the peritoneum was closed with 2-0 chromic sutures.
The right ovary was similarly dissected and removed. Post-
operatively, the patient experienced nausea, cramps and
back pain. She was told this was normal and was dis-
charged. On postoperative day eight, the patient present-
ed to the emergency room with increased nausea and back
pain. An ultrasound demonstrated left: ureteral obstruction.
A urologist found a one- to two-cm necrotic segment of the
ureter and chromic sutures in the vicinity. Uretero-ureteros-
tomy was performed followed by an uneventful recovery.
ALLEGATIONS
Lack of informed consent and battery on her person
by removing her left ovary without her consent and neg-
ligence during surgery.
JOURNALSOGC
JUDGEMENT
July 1996. The judge stated that the standard con-
sent was not sufficient to permit the removal of the left
ovary in the absence of any immediate threat to the
patient's life. The action of negligence was dismissed as
the surgeon's operating room record indicated that "the
ureter was identified well below the area of dissection."
The plaintiff failed to prove that a suture was the cause
of the obstruction which was in any event a recognized
complication of abdominal surgery. As the patient would
have required removal of her left ovary within one year
and there was no evidence that hormone replacement
therapy was harmful to her, the judge limited damages
to $20,000.
CASE 6: HYSTERECTOMY, RIGHT
OOPHORECTOMY, LEFT URETEROVAGINAL
FISTULA
FACTS
During a simple abdominal hysterectomy and right
salpingo-oophorectomy the gynaecologist inadvertently
tied the left ureter to the upper vault of the patient's
vagina, resulting in ureterovaginal fistula formation. The
patient subsequently had to have her left: ovary removed
and her ureter re-implanted by a urologist. This was
followed by an uneventful recovery.
ALLEGATIONS
The 70-year-old doctor was negligent in failing to
wear his eyeglasses during the operation and, therefore,
negligent in his performance of the surgery.
JUDGEMENT
The trial judge found as a fact that the doctor was
not wearing his glasses when he operated on the plain-
tiff and that he was responsible for the plaintiff's dam-
ages. The doctor appealed.
THE ApPEAL
November 1996. The Court of Appeal upheld the
appeal with costs. The court concluded that the defen-
dant's eyesight or lack thereof made no difference to his
performance of surgery because such surgery is a "blind
procedure." Accordingly, the defendant's eyesight
could not have caused or contributed to the incident
39 JAN UARY 1999
 As stated in an article in TI1e New England Journal of Medicine,
Dlclectin is the dr-ug of choice for NVP. ,,' r : . •J 1 'I '" ' II., ,

New England Journal of Medicine . I I ., I·

 , , ,
in question which is furthermore a risk of the procedure
even when competently performed.
CASE 7: HYSTERECTOMY, URETEROVAGINAL
FISTULA
FACTS
The plaintiff underwent a hysterectomy without
complications but five days later she began to experience
discharge of urine from her vagina.
ALLEGATIONS
Negligence in performing the surgery.
JUDGEMENT
March 1991. The judge made a finding that the
likely cause of the injury during surgery was some trauma
to the ureter which weakened it and caused it to rupture
with the passage of time. Furthermore, he found that the
surgeon's practice of using a second layer of sutures to close
the vaginal vault was a technique which only the defen-
dant used, and that placing more sutures than necessary
increased the risk of damage to the ureter. The judge also
speculated that the surgeon used an inadequate technique
to displace the bladder, "and as the operative report was
brief, an adverse inference was drawn regarding the blad-
der displacement. There was some delay in diagnosing the
fistula but the patient recovered uneventfully after cor-
rective surgery. The judge ruled for the plaintiff.
CASE 8: HYSTERECTOMY, URETEROVAGINAL
FISTULA
FACTS
The plaintiff had a long-standing history of painful
menstrual periods with excessive bleeding. Investigation
showed that she had an enlarged uterus with fibroids.
Approximately 2.5 weeks post-hysterectomy, the plain-
tiff awoke having soaked her bed clothes. Several tests
were performed which excluded a vesicovaginal fistula.
The plaintiffs theory was that a suture was passed either
through or around one of the ureters. The defendant's
theory was that the ureter became obstructed in the post-
operative period by the development of a lymphocoele
or haematoma which put lateral pressure on the ureter
causing the kink and impeding the normal flow of urine
from the kidney.
JOURNAL SOGC
JUDGEMENT
June 1991. The judge found that the plaintiff's experts'
theory was not consistent with many of the findings and
as such, the plaintiff's case failed.
CASE 9: HYSTERECTOMY, PARTIAL LEFT
URETERAL OBSTRUCTION
FACTS
A perimenopausal patient with dysfunctional uter-
ine bleeding sustained a partial obstruction of her left
ureter following a hysterectomy. The plaintiff pleaded
res ipsa loquitur, however, evidence was forthcoming from
both the plaintiff's and the defendant's experts that such
damage to the ureter as kinking could occur in the
absence of negligence. The defendant had used a stapling
device and one of the plaintiff's theories was that this
caused the damage.
ALLEGATIONS
Indications for hysterectomy and alternative thera-
pies were not discussed; lack of informed consent and
negligence in performing the surgery.
JUDGEMENT
September 1991. The judge found that if a staple had
injured the ureter it would have severed it rather than
causing a partial blockage. He concluded that on the bal-
ance of probabilities, the defendant met a reasonable
standard of care in recommending and performing the
hysterectomy. The defendant did not advise the plain-
tiff of the risk of ureteric damage. However, the court
concluded that a physician's duty does not go so far as to
place an obligation to alert a patient to every possible
complication. The judge did not believe this was a risk
that had to be disclosed to the patient, and he accepted
the fact that injury to the ureter could be caused and
could occur in the absence of negligence. As such, the
maxim, res ipsa loquitur had no application based upon
the facts in this case. The action was dismissed.
The maxim, res ipsa loquitur (Latin: the thing speaks
for itself) is applicable only in those instances in which
negligence is clear and obvious even to a lay person, as
in foreign object cases in which a surgeon leaves a sponge
in the patient. It refers to circumstantial evidence, and
the burden of proof shifts to the defendant to establish
41 JAN UARY 1999
 , , ,
that the complications arising from the surgery are not a
result of any negligence on the part of the surgeon.
CASE 10: HYSTERECTOMY, RIGHT URETERAL
OBSTRUCTION
FACTS
The physician encountered difficulty in freeing the
right uterosacral ligament because of fibrous tissue and,
in the course of dissection, traumatized a vein causing
bleeding. The vessel was sutured and the hysterectomy
was completed. Subsequently, the plaintiff showed signs
and symptoms of ureteral obstruction and ultrasound
evaluation confirmed it. A further laparotomy revealed
that the ligation carried out to stop the bleeding of the
vein had caught the ureter at its distal junction.
ALLEGATIONS
Lack of informed consent and negligence during
surgery.
JUDGEMENT
January 1994. There was no lack of informed consent
as the plaintiff would in all likelihood have accepted
the surgery even if she had been told of a 0.5 percent risk.
The physician was found not negligent in mistakengly
suturing the ureter because the conditions in which he
had to intervene were both urgent and difficult given the
number of adhesions. The action was dismissed.
CASE 11: BILATERAL OOPHORECTOMY,
URETERAL OBSTRUCTION
FACTS
The plaintiff underwent a bilateral salpingo-
oophorectomy for chronic pelvic pain. Initially in the post-
operative period, she seemed to be recovering normally,
but she subsequently developed symptoms which led to the
diagnosis of a blocked ureter. The plaintiff had a nephros-
tomy tube inserted and subsequent repair of the ureter.
ALLEGATION
Negligence in the conduct of surgery.
JUDGEMENT
March 1994. The trial judge found that the block-
age of the ureter was caused by a suture. The defence
JOURNAL SOGe
expert's evidence was that such an injury could occur
without negligence where there was difficulty in identi-
fying the ureter. The defendant's evidence, however, was
that he visualized the ureter throughout the operation
and as the plaintiff's expert testified if the ureter was vis-
ible there could be no problem in seeing the suture
through it, the defendant had a duty to observe where
the sutures were placed and not to suture in areas which
might have caused problems. The defendant's conduct
was found to be below standard for failing to note that
the suture had come in contact with the ureter. When
determining damages, the trial judge noted that ureter-
al injury was not the cause of all the plaintiff's com-
plaints. Although the damages assessed were not
excessive ($20,000), the decision is under appeal.
CASE 12: HYSTERECTOMY AND BILATERAL
OOPHORECTOMY, OBSTRUCTED URETER
FACTS
The plaintiff had an abdominal hysterectomy and
bilateral salpingo-oophorectomy for a large left adnexal
mass. The postoperative course was normal but the
plaintiff eventually consulted another specialist who
diagnosed left ureteric obstruction.
ALLEGATIONS
Lack of informed consent, negligence in performing
the surgery and negligence in failing to diagnose the injury.
JUDGEMENT
May 1994. The court dismissed the plaintiff's expert's
version that the ureters should have been dissected at the
time of surgery. The expert testimonies confirmed that the
plaintiff showed no sign of any problem in the postopera-
tive period while under the care of the defendant. Even if
she had been advised of the possible risk of trauma to the
ureter, the plaintiff would have accepted the surgery given
the presence of a tumour. Such a trauma is a risk inherent
in this kind of intervention. The action was dismissed.
CASE 13: LEFT OOPHORECTOMY, URETERAL
INJURY
FACTS
A 38-year-old patient had a laparotomy for tuballig-
ation. The doctor noted that the left tube and ovary were
42 JANUARY 1999
 , , ,
a complex mass of endometriosis and he proceeded to
remove the entire adnexa. During blunt dissection of the
ovary, bleeding was encountered from the posterior leaf
of the broad ligament. The bleeding was stopped with a
mattress suture in the broad ligament. Postoperatively,
the patient developed abdominal distension which wors-
ened over the next month. Subsequently, the distension
was found to be due to free intra-abdominal urine from
an injured left ureter.
ALLEGATIONS
Negligence in performing the surgery, negligence in
failing to diagnose postoperatively. Res ipsa loquitur was
argued.
JUDGEMENT
October 1976. Common experience applied to the
evidence presented in this case does not indicate that
the mere occurrence of the injury may be considered as
proof that reasonable care has not been used. The judge
concluded that the maxim, res ipsa loquitur did not apply
to this case. The action was dismissed.
DISCUSSION
In all 13 cases, the allegation oflack of informed con-
sent was defeated by the causation aspect of the consent
as under the conditions a reasonable person would have
agreed to surgery even if the risk of ureteral injury had
been disclosed. Furthermore, the risk of ureteral injury
does not have to be disclosed as it is a known complica-
tion with a frequency of occurrence of less than 0.5
percent and it is not considered a material risk. The
maxim, res ipsa loquitur, argued in two of the cases, was
also rejected as inapplicable.
The use of pre-operative IYP, ureteral stenting or
intra-operative dyes is of little value in preventing ureter-
al injuries and as these procedures may pose certain risks
in themselves, they have not been considered as the
standard of care.
In nine of the 13 cases (70%), the judge ruled in
favour of the defendant, accepting the fact that injury to
the ureter could be caused and could occur in the
absence of negligence. There were seven ureteral injuries
during oophorectomy. It is conceivable that during
oophorectomy ureteral injuries could have been pre-
vented if the ureters had been exposed prior to the
clamp, cut and ligate technique of the surgical steps.
JOURNAL SOGC
In our centre, residents are routinely taught to iden-
tify and dissect the ureter at every step of pelvic surgery.
Prior to the ligation of the infundibulopelvic ligament,
the round ligament is identified, ligated and divided. The
parietal peritoneum is incised parallel and lateral to the
infundibulopelvic ligament up to the level of the pelvic
brim. The ureter is always found crossing the external
iliac artery, one cm from the bifurcation, and it can
always be followed down into the pelvis attached to the
parietal peritoneum. The infundibulopelvic ligament is
then ligated and divided while the ureter is still under
direct vision. The adnexa is elevated and the dissection
plane is carried sharply downwards with the ureter under
direct vision to the level of the uterine vessels where it
tunnels under the vessels. Dissection of the ureter at this
level may be counter-productive as it may result in bleed-
ing or trauma to the ureter unless the surgeon has been
trained in this specialized technique. At this level, the
uterine vessels are skeletonized off the posterior leaf of the
broad ligament. The bladder is dissected away from the
low anterior uterine segment and the cervix. These steps
move the ureter laterally and downwards away from the
uterine vessels prior to the clamp, cut and ligation step.
In summary, the cardinal rules in the management
of ureteral injuries during gynaecological surgery are:
1. Prevention. During pelvic surgery, the surgeon must
be conscious of the location of the ureter during every
step of the procedure. Routine dissection of the ureter
during pelvic surgery is not the standard of care, how-
ever, when the normal pelvic anatomy is distorted by
disease, the need for ureteral dissection should be
addressed. Structures should not be clamped, cut or
ligated unless the position of the ureter is well known.
z. Identification of the injury. If injury to the ureter is
suspected intra-operatively, the ureter should be
identified, and its intregrity assessed with dyes inject-
ed intravenously or into the bladder. Retrograde
insertion of a ureteral catheter with the bladder open
or through the cystoscope may also be considered. A
paediatric Foley catheter can be used through the
open bladder. The appropriate repair can be per-
formed without consequences.
3. High index of suspicion. In the postoperative peri-
od, the occurence of such signs or symptoms of
ureteral damage as nausea, undiagnosed fever, per-
sistent flank pain or mid-back pain should suggest
investigation of the renal system.
43 JANUARY 1999
 OSOGe
International
CME Programme
March 7 -11, 1999
• Education tailored to needs of specialists and family
physicians.
• Plenary sessions plus several interactive small group,
case discussion sessions on many topics. Bring a case
to discuss with your colleagues.
• Two sets of 2-hour concurrent sessions on advanced
gyn surgery, gyn office practice, obstetrics and colposcopy.
• Scientific program finished by noon each day.
Programme
international de FMC
7 au 11 mars 1999
• Formation sur mesure pour repondre aux besoins des
specialistes et des medecins de famille
• Seances plenieres et nombreuses seances interactives en
petits groupes, discussions de cas avec plusieurs choix de
sujets. Venez presenter un cas qui vous interesse pour
en discuter avec vas collegues.
• Deux series de sessions simultanees de deux heures en
chirurgie gynecologique avancee, en pratique de la gynecologie
en cabinet, en obstetrique et en colposcopie
• Programme scientifique se terminant i! midi taus les jours

Topics Sujets
1_ CVD. Osteoporosis, Urogenital health - special problems. 1. Affection cardiovasculaire, osteoporose, sante urogenitale -
2. Advanced Gynaecological surgery, colposcopy, outpatient problemes specifiques
hysteroscopy 2. Chirurgie gynecologique avancee, colposcopie, hysteroscopie
3. Office Gynaecology - guide to practice - What's new? en consultation externe
What's needed? 3. Gynecologie en cabinet - guide relatif ilIa pratique - quoi de
4. Controversies - annual pap smear, Breast Cancer &. neuf?, quels sont les besoins?
Hormones, 2nd &. 3rd generation OCs, LAVH vs. Vaginal 4. Sujets controverses - test de Papanicolaou annuel, cancer du
5. Obstetrics - Induction, Post Term, VBAC, Antenatal testing, sein et hormones, contraceptifs oraux de 2e et 3e generation,
Healthy Beginnings, Postpartum Haemorrhage HVAL par opposition i! vaginale
6. Assisted mid-pelvic delivery in the year 2000 and beyond. 5. Obstetrique - declenchement grossesse prolongee, AVAC,
7. Low dose OCs &. Acne. examens prenatals, partir du bon pied, hemorragie post-partum
8. Medical legal cases in case room and OR, operative OBS 6. Accouchement par forceps moyens I ventouse ill' aube
delivery de l'an 2000 et au-deli!
9. Bisphosphonates, SERMs, Menorrhagia - surgical, medical. 7. Contraceptifs oraux afaible dose et acne
10. Consensus statements on Contraception, Endometriosis, 8. Poursuites devant les tribunaux pour des actes medicaux poses
Menopause en salle d' operation, accouchement operatoire en obstetrique
9. Bisphosphonates, SERM, Menorragie - chirurgicale, medicale
10. Consensus sur la contraception, l'endometriose, la menopause

Planning Committee I Main Faculty Comite de planipcation I con/erenciers principaux

Dr. Dianne Miller, Co-chair, Vancouver, BC Dr Dianne Miller, codirecteur, Vancouver (C.-B.)
Dr. Carl Nimrod, Co-chair, Ottawa, ON Dr Carl Nimrod, codirecteur, Ottawa (Ont.)
Dr. Philippe Laberge, Quebec, QC Dr Philippe Laberge, Quebec (Qc)

Registration Fee is $450 up to January 15, 1999. Les frais d'inscription sont de 450 $ ;usqu'au 15 ;anvier 1999,
Exception: Junior members' fee is $225 up to January 15, 1999. ii l'exception des membres ;uniors pour qui les /rais d'inscription
CME credits for both specialists and sont de 225 $ ;usqu'au 15 ;anvier 1999. Des credits de FMC seront
family physicians. accordes aux specialistes de meme qu'aux medecins de famille.

For ICME information &. registration, please contact SOGC:

Pour tout renseignement ou pour vous inscrire, veuillez communiquer avec la SaGe:
Tel./tel. : (613) 730·4192 Fax/telec. : (613) 730·4314 Email/courriel : sogcwebmaster@medical.org

For information & reservations concerning travel arrangements / Pour information et reservation concernant le voyage

CarlsonWagonlit ~r
Owned et! Operated by / Sous la direction et la propriete de Voyages Lemay et! Voyages Verdun
ICME Line/Ligne FMC: (514) 287·1144 Toll Free/Sans frais : 1·800·280·9967
Fax/telec. : (514)843.5680 Toll Free Fax/telec. sans frais : 1·800·641·3761 Email/courriel: ICME@carlson·vv. com
Quebec Permit Holder I Permis du Quebec
 , , ,
REFERENCES
1. A practical approach to informed consent. College
Notices. Issue No.5. January 1983. The College of Physi-
cians and Surgeons of Ontario, 80 College Street, Toron-
to, Ontario, Cariada, N5G 2E2.
2. Sampson JA. Ligation and clamping of the ureter as com-
plication of surgical operations. Am J Med 1902;4:693.
3. Newell QU. Injury to ureter during pelvic operation. Ann
Surg 1939;109:48.
4. Benson RC, Hinmann F Jr. Urinary tract injuries in obstet-
rics and gynecology. Am J Obstet GynecoI1955;70:467.
5. Everett HS, Mattingly RF. Urinary tract injuries resulting
from pelvic surgery. Am J Obstet Gynecol 1956;71 :502.
6. Daly JW, Higgins KA. Injury to the ureter during gyneco-
logic surgical procedures. Surg Gynecol Obstet
1988;167:19-22.
7. Mann WJ. Intentional and unintentional ureteral surgical
treatment in gynecologic procedures. Surgery
1991;172:453.
8. Thompson JD. Operative injuries to the ureter: preven-
tion, recognition and management. In: Telinde's Opera-
tive Gynecology. 7th ed. Philadelphia. JB Lippincott,
1992:749-83.
9. Goodno JA Jr, Powers TW, Harris YD. Ureteral injury in
gynecologic surgery: a ten-year review in a community
hospital. Am J Obstet GynecoI1995;172:1817-22.
10. Scott TA, Webster RD. Iatrogenic urologic injuries during
obstetrical and gynaecological surgery. J Soc Obstet
Gynaecol Can 1996; 18:595-8.
11. Harkki-Siren P, Sjoberg J, Tiitenen A. Urinary tract injuries
after hysterectomy. Obstet GynecoI1998;92:113-8.
12. Meikle SF, Nugent EW, Orleans M. Complications and
recovery from laparoscopic assisted vaginal hysterectomy
compared with abdominal and vaginal hysterectomy. A
review. Obstet Gynecol 1997;89:304-18.
13. Saidi MH, Sadler KR, Vancaillie TG et al. Diagnosis and
management of serious urinary complications after major
operative laparoscopy. Obstet GynecoI1996;87:272-6.
14. Hulka JF, Levy BS, Parker WH, Phillips JM. Laparoscopic-
assisted vaginal hysterectomy: American Association of
Gynecologic Laparoscopists' 1995 Membership Survey.
JAm Assoc Gynecol Laparoscopists 1997;4:167-71.
15. Simel D, Matchar D, Piscitelli J. Routine intravenous pyel-
ogram before hysterectomy in cases of benign disease:
possibly effective, definitely expensive. Am J Obstet
GynecoI1988;159:1049-53.
16. Brubaker LT, Wilbanks GD. Urinary tract injuries in pelvic
surgery. Surg Clin North Am 1991;71:963-76.

JOURNAL SOGe 45 JANUARY 1999